Cho Joon Hyun
Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea.
Medicine (Baltimore). 2019 Jul;98(30):e16519. doi: 10.1097/MD.0000000000016519.
Esophageal hemorrhage may occasionally develop subsequent to esophagitis and stasis ulcer, but potentially fatal esophageal bleeding is very uncommon in primary achalasia.
We describe a case of a 64-year-old man with long-standing achalasia and megaesophagus who presented acute episodes of life-threatening upper gastrointestinal bleeding.
Five esophagogastroduodenoscopies (EGD) were conducted and during each large amount of static food, bloody material, and clots should be removed from the esophagus because of impaired esophageal transit. Eventually, diffuse multiple irregular ulcers were observed in the middle and lower portions of the esophagus that were presumed to have been caused by aspirin stasis based on considerations of previous drug use. EGD also revealed a 2.0 × 2.5 cm flat nodular lesion with central ulceration at the mid-to-lower esophagus and adherent blood clots suggestive of bleeding stigma. The biopsy specimen demonstrated esophageal cancer. Accordingly, a diagnosis of massive esophageal hemorrhage in long-standing achalasia complicated by squamous cell carcinoma, possibly triggered by acute mucosal irritation and ulcer caused by aspirin stasis, was made. The patient then successfully underwent the Ivor-Lewis operation. Resultantly, the tumor was diagnosed as moderately differentiated squamous cell carcinoma stage IIA (T2N0M0).
The patient's postoperative course was uneventful, and no evidence of tumor recurrence or metastasis has been found during the 6 months of follow-up examination. He was tolerating normal food with only minimal reflux symptoms.
Although, fortunately in the described case, esophageal cancer was diagnosed at a relatively early stage because it is the acute presentation of life-threatening upper gastrointestinal bleeding, this report cautions that when symptoms of dysphagia are aggravated, taking drugs capable of acting as local irritants, such as aspirin, could cause fatal esophageal hemorrhage in achalasia.
食管炎和淤滞性溃疡偶尔会引发食管出血，但在原发性贲门失弛缓症中，潜在致命性的食管出血非常罕见。
我们报告一例64岁男性，患有长期贲门失弛缓症和巨食管，出现危及生命的上消化道急性出血发作。
进行了5次食管胃十二指肠镜检查（EGD），每次检查时，由于食管蠕动受损，都应从食管中清除大量的静止食物、血性物质和血凝块。最终，在食管中下段观察到弥漫性多发不规则溃疡，基于既往用药情况考虑，推测是阿司匹林淤滞所致。EGD还显示食管中下段有一个2.0×2.5厘米的扁平结节状病变，中央有溃疡，并有附着的血凝块，提示有出血迹象。活检标本显示为食管癌。因此，诊断为长期贲门失弛缓症并发鳞状细胞癌导致的大量食管出血，可能是由阿司匹林淤滞引起的急性黏膜刺激和溃疡触发。患者随后成功接受了Ivor-Lewis手术。结果，肿瘤被诊断为中度分化鳞状细胞癌IIA期（T2N0M0）。
患者术后恢复顺利，在6个月的随访检查中未发现肿瘤复发或转移的迹象。他能够耐受正常食物，只有轻微的反流症状。
虽然在所描述的病例中幸运的是，由于是危及生命的上消化道出血的急性表现，食管癌在相对早期被诊断出来，但本报告提醒，当吞咽困难症状加重时，服用能够作为局部刺激物的药物，如阿司匹林，可能会在贲门失弛缓症患者中导致致命的食管出血。
